YMCA of Lancaster and Fairfield County Child Protection Report
Report Details
Full Name
*
First Name
Middle Name
Last Name
Role of Individual Filing Report
*
Employee
Volunteer
Member
Youth Participant
Other
Date of Occurrence
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Occurrence
*
Hour Minutes
AM
PM
AM/PM Option
Other Individuals Involved / Witnesses
Type of Complaint
*
Bullying
Harassment or discrimination
Inappropriate Behavior by Employees/Volunteers
Inappropriate Behavior by Non-Employees/Volunteers
Other violations of law or policy
Incident Description
Describe the situation
*
Has this situation occurred previously?
Describe the remedy you seek
*
Submission and Review
Submitted By
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Location / Branch
*
Signature
*
Date of Submission
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By
First Name
Middle Name
Last Name
Date of Review
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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